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<body lang=EN-US style='tab-interval:.5in'>

<div class=Section1 style="width: 592; height: 1295">

<table border="0" cellpadding="0" cellspacing="0" width="100%" height="1">
  <tr>
    <td width="100%" height="1">
  <h6><font size="2">CỘNG HOÀ XÃ HỘI CHỦ NGHĨA VIỆT NAM <o:p></o:p></font></h6>             
  <p class=MsoNormal align=center style='text-align:center;word-spacing:0in'><span
  style='font-family: Arial; mso-font-kerning: 14.0pt'><font size="2">Độc lập-Tự             
  do -Hạnh phúc<u1:p> </font> </span></p>             
    </td>
  </tr>
</table>

<p class=MsoNormal align=center style='text-align:center;word-spacing:0in'><span
style='font-family: Arial; mso-font-kerning: 14.0pt'><font size="2">***************</font></span></p>

<p class="MsoNormal" align="center" style="margin:0in;margin-bottom:.0001pt;
text-align:center"><b><span style="font-family: Arial"><font size="2">ĐƠN XIN   
CẤP GIẤY CHỨNG NHẬN<o:p>  
</o:p>  
</font></span></b></p>
<p align="center"><b><span style="font-family: Arial; mso-fareast-font-family: Times New Roman; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA"><font size="2">   
SỬ DỤNG ĐẤT</font></span></b>      

<p class=MsoNormal style='word-spacing:0in' align="center">&nbsp;</p>  

<p class="MsoNormal" style="word-spacing: 0in" align="center"><b><i><u><span style="font-size:10.0pt;mso-bidi-font-size:
12.0pt;font-family:Arial">Kính gửi</span></u></i></b><span style="font-size:  
10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">: <b>UBND xã (thị   
trấn)… 1. Thị trấn Phú Mỹ………………………………………………..<o:p>
</o:p>  
</b></span></p>
<table width="757" border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;border:none;
 mso-border-alt:solid windowtext .5pt;mso-padding-alt:0in 5.4pt 0in 5.4pt;
 mso-border-insideh:.5pt solid windowtext;mso-border-insidev:.5pt solid windowtext">
  <tr>
    <td width="753" valign="top" style="width:5.7in;border:solid windowtext 1.0pt;
  mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt">
      <p class="title" align="center"><span style="font-size:10.0pt;mso-bidi-font-family:Arial">I   
      - PHẦN KÊ KHAI CỦA NGƯỜI SỬ DỤNG ĐẤT<o:p>  
      </o:p>  
      </span></p>
    </td>
  </tr>
  <tr>
    <td width="753" valign="top" style="width:5.7in;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
  padding:0in 5.4pt 0in 5.4pt">
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">1   
      - Người sử dụng đất</span></b><span style="font-size:10.0pt;mso-bidi-font-size:  
  12.0pt;font-family:Arial">:<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">1.1.   
      Tên người sử dụng đất: <i>(Đối với cá nhân)<o:p>  
      </o:p>  
      </i></span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Họ   
      và tên:&nbsp;&nbsp;&nbsp; namnh&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      Sinh năm:&nbsp;&nbsp;&nbsp; 8/6/2007&nbsp;&nbsp;&nbsp;&nbsp;   
      .CMND số:&nbsp;&nbsp; 94876&nbsp;&nbsp;&nbsp; do công an   
      tỉnh (thành phố):&nbsp;&nbsp; CA.Tỉnh Bà Rịa - Vũng Tàu&nbsp;&nbsp;&nbsp;&nbsp;   
      cấp ngày<span style="mso-tab-count:1">&nbsp;&nbsp;</span>&nbsp;&nbsp; 16/6/2007<o:p>  
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">1.2   
      Tên người sử dụng đất: <i>(Đối với hộ gia đình)<o:p>  
      </o:p>  
      </i></span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Họ   
      và tên chồng/v&#7907; :&nbsp; namnh&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      Sinh năm:&nbsp; 8/6/2007&nbsp;&nbsp;&nbsp; CMND   
      số:&nbsp;&nbsp; 94876&nbsp;&nbsp;&nbsp;&nbsp; do công an   
      tỉnh (thành phố):&nbsp;&nbsp; CA.Tỉnh Bà Rịa - Vũng Tàu&nbsp;&nbsp;&nbsp;   
      cấp ngày<span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;   
      </span>16/6/2007<o:p>
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Họ   
      và tên v/chồng ợ:&nbsp;&nbsp; NGUYEN HONG NAM&nbsp;&nbsp;&nbsp;&nbsp; ..Sinh năm:&nbsp;   
      9/6/2007&nbsp;&nbsp; CMND số:&nbsp;&nbsp; 384765&nbsp;&nbsp;&nbsp;   
      do công an tỉnh (thành phố):&nbsp;&nbsp; CA.Tỉnh Bà Rịa - Vũng Tàu&nbsp;&nbsp;   
      cấp ngày<span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;   
      </span>23/6/2007<o:p>
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Sổ   
      hộ khẩu gia đình số:&nbsp;&nbsp;&nbsp; 2134&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;   
      cấp ngày:&nbsp;&nbsp;&nbsp; <o:p>  
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">1.3   
      Địa chỉ thường trú:&nbsp;&nbsp;&nbsp; Tran Nao, Quan 2, TP HCM&nbsp;</span></p>  
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p> 
    </td>
  </tr>
  <tr>
    <td width="753" valign="top" style="width:5.7in;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
  padding:0in 5.4pt 0in 5.4pt">
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2   
      - Thửa đất xin cấp giấy chứng nhận quyền sử dụng đất</span></b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">:<o:p> </o:p></span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><o:p>        </o:p>
      </span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.1.   
      Thửa đất số:&nbsp; 234&nbsp;&nbsp;&nbsp;&nbsp; ..;   
      2.2. Tờ bản đồ số:&nbsp; 567845</span></p>  
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.3.   
      Địa chỉ tại:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Tran Nao, Quan 2, TP HCM.<o:p> 
      </o:p>  
      </span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.4.   
      Diện tích:&nbsp; 1500&nbsp;&nbsp;&nbsp;&nbsp; .m<sup>2</sup>;   
      </span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Hình thức sử dụng:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;</span></p>      
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"> + Sử dụng riêng&nbsp;  : 
          <span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">1000&nbsp; .m<sup>2<o:p> </o:p></sup></span></span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:right dotted 6.0in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">+ Sử dụng chung:&nbsp; <sup><o:p></o:p></sup></span>4000&nbsp;&nbsp; .m<sup>2<o:p> 
          </o:p>
      </sup></span></p>      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span><span style="mso-tab-count:3">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><sup><o:p></o:p>
      </sup></span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.5.   
      Mục đích sử dụng đất:</span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"> 1. Đất làm nhà ở<BR> 2. Đất sản xuất nông nghiệp </span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.6.   
      Thời hạn sử dụng đất:&nbsp;&nbsp;&nbsp; Vo thoi han..<o:p> 
      </o:p>  
      </span></p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">2.7.   
      Nguồn gốc sử dụng đất: (Ghi rõ được cấp năm nào, do   
      cấp nào cấp hay đất của ông cha)<o:p></span></p> 
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt; font-family: Arial"> 1. Đất do tổ tiên để lại<BR> 2. Đất ông cha</span><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"></o:p></span>&nbsp;</p>
      <p class="MsoHeader" style="margin:0in;margin-bottom:.0001pt;tab-stops:.5in">&nbsp;</p>
    </td>
  </tr>
  <tr>
    <td width="753" valign="top" style="width:5.7in;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
  padding:0in 5.4pt 0in 5.4pt">
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">3   
      – Tài sản gắn liền với đất</span></b><span style="font-size:10.0pt;mso-bidi-font-size:  
  12.0pt;font-family:Arial">:<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">3.1.<span style="mso-spacerun:yes">&nbsp;  
      </span>Loại nhà hoặc công trình xây dựng:&nbsp;&nbsp; Khong biet.<o:p> 
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>Diện tích xây dựng:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2000.<o:p> 
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">3.2.<span style="mso-spacerun:yes">&nbsp; 
      </span>Cây rừng, cây lâu năm:&nbsp;&nbsp; .<o:p> 
      </o:p>  
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>a) Loại cây:  lau nam.<o:p></o:p></span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>b) Diện tích có cây:   1500</span></p>
      </td>
  </tr>
  <tr style="mso-yfti-lastrow:yes">
    <td width="753" valign="top" style="width:5.7in;border:solid windowtext 1.0pt;
  border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
  padding:0in 5.4pt 0in 5.4pt">
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">4   
      - Những giấy tờ nộp theo đơn này gồm:<o:p>  
      </o:p>  
      </span></b></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><font size="2"> 1. Đơn xin cấp giấy chứng nhận quyền sử dụng đất<BR> 2. Tờ khai lệ phí trước bạ<BR> 3. Tờ khai thuế chuyển quyền sử dụng đất</font></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<b><o:p>
      &nbsp;
      </b></span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><b>
      </o:p>
      </b></span></p>
    </td>
  </tr>
</table>
<p class="MsoNormal"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;
font-family:Arial">Tôi xin cam đoan nội dung kê khai trên là đúng.</span></p> 
<blockquote>
  <blockquote>
    <blockquote>
      <p class="MsoNormal"><span style="mso-tab-count: 3; font-size: 10.0pt; mso-bidi-font-size: 12.0pt; font-family: Arial">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  
      </span><i><font size="2">Tân Thành, ng&#224;y 26 th&#225;ng 06 n&#259;m 2007</font></i><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt; 
font-family:Arial"><o:p>
      </o:p>
      </span></p>
    </blockquote>
  </blockquote>
</blockquote>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-tab-count:5">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp; 
</span><b>Người viết đơn<o:p> 
</o:p> 
</b></span></p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-spacerun:yes">&nbsp;&nbsp;</span><span style="mso-tab-count:5">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
</span><span style="mso-spacerun:yes">&nbsp;</span>(Ký và ghi rõ họ tên)<o:p> 
</span></p> 
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt">&nbsp;</p>
<p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">
</o:p>
</span></p>

</div>

<table class="MsoNormalTable" border="1" cellspacing="0" cellpadding="0" style="border-collapse: collapse; mso-table-layout-alt: fixed; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; border-style: none; border-width: medium" width="564" height="765">
  <tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:41.8pt">
    <td width="548" valign="top" style="mso-border-alt: solid windowtext .5pt; border: 1.0pt solid windowtext; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in" height="34" bordercolor="#FFFFFF" bgcolor="#FFFFFF" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF"><span style="font-size:10.0pt;mso-bidi-font-family:Arial">II 
      - PHẦN XÁC NHẬN CỦA UỶ BAN NHÂN DÂN XÃ, PHƯỜNG, THỊ 
      TRẤN ĐỐI VỚI HỘ GIA ĐÌNH, CÁ NHÂN</span></td>
  </tr>
  <tr style="mso-yfti-irow:1;height:247.9pt">
    <td width="548" valign="top" style="mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; border-left: 1.0pt solid windowtext; border-right: 1.0pt solid windowtext; border-top-style: none; border-top-width: medium; border-bottom: 1.0pt solid windowtext; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in" height="351">
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">- 
      Nguồn gốc và thời điểm sử dụng đất: (Ghi rõ được 
      cấp năm nào, do cấp nào cấp hay đất của ông cha)<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">- 
      Tình trạng tranh chấp, khiếu nại về đất đai: 
      …………………………………………………..<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">- 
      Sự phù hợp với quy hoạch sử dụng đất: 
      ………………………………………….…………..<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Ngày……..tháng……năm 
      200….<span style="mso-tab-count:1"> </span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>Ngày……..tháng……năm 200….<span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>Cán bộ địa chính<span style="mso-spacerun:yes">&nbsp; </span><span style="mso-tab-count:2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>TM. 
      Uỷ ban nhân dân xã (Thị trấn)<o:p>
      </o:p>
      </span></b></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>(Ký và ghi rõ họ tên)<span style="mso-tab-count:5">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><b><i>Chủ tịch</i></b></span><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"></o:p>
      </span></b></td>
  </tr>
  <tr style="mso-yfti-irow:2;height:20.2pt">
    <td width="548" valign="top" style="mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; border-left: 1.0pt solid windowtext; border-right: 1.0pt solid windowtext; border-top-style: none; border-top-width: medium; border-bottom: 1.0pt solid windowtext; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in" height="29">
      <p class="title" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-family:Arial">III 
      - KẾT QUẢ THẨM TRA CỦA PHÒNG TÀI NGUYÊN VÀ MÔI TRƯỜNG<o:p>
      </o:p>
      </span></p>
    </td>
  </tr>
  <tr style="mso-yfti-irow:3;mso-yfti-lastrow:yes">
    <td width="548" valign="top" style="mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; border-left: 1.0pt solid windowtext; border-right: 1.0pt solid windowtext; border-top-style: none; border-top-width: medium; border-bottom: 1.0pt solid windowtext; padding-left: 5.4pt; padding-right: 5.4pt; padding-top: 0in; padding-bottom: 0in" height="343">
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">………..………………………………………………………………………………………………<o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><o:p>
      &nbsp;</o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial">Ngày……..tháng……năm 
      200….<span style="mso-tab-count:1"> </span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>Ngày……..tháng……năm 200….<span style="mso-tab-count:1">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><o:p>
      </o:p>
      </span></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><b><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>Người thẩm tra hồ sơ<span style="mso-spacerun:yes">&nbsp; </span><span style="mso-tab-count:2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>Phòng 
      Tài nguyên và Môi trường<o:p>
      </o:p>
      </span></b></p>
      <p class="MsoNormal" style="margin:0in;margin-bottom:.0001pt"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Arial"><span style="mso-spacerun:yes">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
      </span>(Ký và ghi rõ họ tên)<span style="mso-tab-count:5">&nbsp;&nbsp;&nbsp; 
      </span></span></td>
  </tr>
</table>

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